Swedish work on containment of antibiotic resistance Tools, methods and experiences Swedish work on containment of antibiotic resistance Tools, methods and experiences Commitments and conflicts of interest In the case of the Public Health Agency of Sweden’s own experts and specialists who have contributed to reports, any conflicts of interest and commitments are assessed within the framework of their conditions of employment. Regarding external experts and specialists who participate in the Public Health Agency of Sweden’s work on drawing up reports, the agency requires that they submit written declarations of potential conflicts of interest or commitments. Such circumstances may exist if an expert, for example, has received or receives financial remuneration from an organization with interests in the outcome of the matter with which the agency is deal- ing or if there exists an earlier or current standpoint on or involvement in the matter in question such that it may be surmised that impartiality cannot be maintained. The Public Health Agency of Sweden then decides whether circumstances exist that would impede an objective appraisal of the material drawn up and thus affect the agency’s ability to act objectively and impartially. The assessment may result in the expert being able to be engaged for the assignment or that the agency proposes meas- ures concerning the expert’s engagement or that the expert is not judged to be able to participate in the work in question. Those external experts who have contributed to the present report have submitted a declaration of any conflicts of interest or commitments in accordance with the Public Health Agency of Sweden’s requirements before beginning their work. In the judgment of the Public Health Agency of Sweden, there exist no circumstances that might jeop- ardize the agency’s credibility. The declarations and any complementary documents are public documents and may be accessed at the Public Health Agency of Sweden. This title may be ordered from the Public Health Agency of Sweden’s printing service, c/o Strömberg, SE-120 88 Stockholm. Fax: +46 8-779 96 67. E-mail: [email protected]. It may also be downloaded from: www.folkhalsomyndigheten.se/publicerat-material. You are welcome to cite our texts, but please remember to state the source. Images, photographs and illustrations are protected by copyright. In order to use them, permission must be given by the author. © Public Health Agency of Sweden, 2014. ISBN 978-91-7603-011-0 – pdf ISBN 78-91-7603-012-7 – print Photos: p. 54 Robert Blombäck, p. 75 ESCMID, p. 108 Pia Nilzén and p. 119 Stefan Ahlrik Graphic production: AB Typoform Preface Resistant bacteria pose a threat to the global health. Collaboration and exchange of experiences between countries are vital for the work to counteract the increasing resistance development. Sweden is a small country with a relatively low consumption of antibiotics and favourable resistance conditions in an international perspective. Sweden initiated long-term, structured measures early on, characterised by work on both local and national levels with the collaboration of many disciplines and sectors both nationally and locally, which is further described in the report. There is also a long tradition of working for rational use of antibiotics and reduced spread of infec- tions within veterinary medicine, animal husbandry and agriculture. From an interna- tional perspective the level of antibiotic use and the prevalence of resistant bacteria in animals in Sweden is low. This report focuses, however, on human medicine. This report has been produced within a collaboration project with the Indian National Center for Disease Control (NCDC) as a part of Sweden’s and India’s work for rational antibiotic consumption and improved surveillance of antibiotic resistance and is financed by Sida. The Governments of India and Sweden signed an agreement of cooperation in 2009 in the field of healthcare and public health which points out antibiotic resistance as an area for collaborate efforts. Within this agreement there is an ongoing collaboration between NCDC and the Public Health Agency of Sweden. The ambition is that the report or chosen chapters and examples can be useful for other organisations and countries that want to develop or further strengthen their work on rational antibiotic use and resistance surveillance within human medicine. The report can be seen as a “tool-box” where present or previous Swedish tools and expe- riences can be adapted to different countries levels of progress in the area. The Public Health Agency of Sweden Johan Carlson Malin Grape Director General Head Unit for Antibiotic and Infection control Contributors and participants Main editors and authors of the report are Karin Carlin, analyst, and Sonja Löfmark, PhD, micro- biologist, from the Public Health Agency of Sweden and Lars Blad, Deputy Medical Officer for Communicable Disease Control in the county of Västernorrland, chair of the local Strama group and member of the Strama advisory council. The four interviews with the experts were done by Natasha Brieger, who also contributed with English language and text editing. The report is based on interviews with experts with experience of the work against antibiotic resistance and is also based on previous reports from the former national Strama, the Public Health Agency of S weden – former Swedish Institute for Communicable Disease Control, and the National Board of Health and Welfare. Input from reference groups within the area have con- tinuously been collected. Experts contributing to the report Malin André Associate professor, GP Bo Aronsson Associate professor, Senior consultant physician, The Public Health Agency of Sweden Olov Aspevall PhD, Senior consultant physician, The Public Health Agency of Sweden Otto Cars Professor, Senior expert, The Public Health Agency of Sweden Sven Engström PhD, GP Mats Erntell PhD, MD, chairman of Strama Halland and the national Strama advisory council, County medical officer Halland Christian Giske Associate professor, Senior consultant physician, The Public Health Agency of Sweden Malin Grape PhD, MSc Pharmacy, Head of unit, The Public Health Agency of Sweden Håkan Hanberger Professor, Senior consultant physician, Chairman of Strama Östergötland Katarina Hedin PhD, GP chairman of Strama Kronoberg Jonas Hedlund Associate professor in Infectious diseases, Senior consultant physician Jenny Hellman MSc Pharmacy, the Public Health Agency of Sweden Barbro Olsson Liljequist Associate professor, Senior microbiologist, The Public Health Agency of Sweden Christer Norman GP, the Public Health Agency of Sweden Per Åke Jarnheimer MD Infectious diseases and Infection control, Chairman of Strama Kalmar Gunnar Kahlmeter Adj Professor in Clinical Bacteriology Cecilia Stålsby Lundborg Professor, Dept of Public Health Sciences Karolinska Institutet Anders Lundqvist PhD, Senior consultant physician Eva Melander PhD, Senior consultant physician, Chairman of Strama Skåne Sigvard Mölstad Professor, GP Dept Clin Sciences Malmö Ingemar Qvarfordt PhD, MD, Senior Lecturer in Infection Prevention and Control, Nordic School of Public Health, Göteborg Gunilla Skoog MSc Pharmacy, the Public Health Agency of Sweden Stephan Stenmark PhD, MD, chairman of Strama Västerbotten, County Medical Officer Västerbotten County Council Tomas Söderblom Analyst, the Public Health Agency of Sweden Anders Tegnell MD, Director Dept of Monitoring and evaluation, State Epidemiologist, the Public Health Agency of Sweden Anders Ternhag PhD, Senior consultant physician, The Public Health Agency of Sweden Karin Tegmark Wisell MD, Director Dept of Microbiology, the Public Health Agency of Sweden Inga Zetterqvist Infection Control Nurse, the Public Health Agency of Sweden Table of contents Preface ......................................................................................................5 Contributors and participants ....................................................................... 6 Abbreviations .............................................................................................8 Summary .................................................................................................11 Guidance for readers ..................................................................................15 A brief background ....................................................................................16 Chapter 1. An overview of Sweden and the Swedish work on containment of antibiotic resistance in human medicine ............................18 Chapter 2. Strama work ..............................................................................28 Interview with Professor Otto Cars ...........................................................52 Chapter 3. Resistance monitoring ................................................................54 Interview with Professor Gunnar Kahlmeter...............................................73 Chapter 4. Monitoring the use of antibiotics ..................................................75 Interview with Per-Åke Jarnheimer .........................................................107 Chapter 5. Treatment recommendations .....................................................109 Interview with Katarina Hedin ................................................................119 Chapter 6. Communicating rational use of antibiotics .............................. 121 References ..............................................................................................129 Annexes ..................................................................................................133 Abbreviations AOM Acute otitis media ATC Anatomical therapeutic chemical classification system BVC Children’s health centres CASE Software for statistical analyses CDA Communicable disease act CDC Center for Disease Control CeHis Center for eHealth in Sweden CNS Central nervous system COPD Chronic obstructive pulmonary disease CPE Carbapenemase producing enterobacteriaceae CRE Carbapenemase resistant enterobacteriaceae CRP C-reactive protein CVC Central vein catheter DDD Defined daily dose DG-SANCO Directorate general Health and consumers EARSS/ European resistance surveillance system/network EARS-Net ECDC European Centre for Disease Prevention and Control EMA European Medicines Agency ESAC-Net European surveillance of antibiotic consumption network ESBL Extended spectrum beta lactamases ESBL ESBL, plasmid mediated, inhibited by clavulanic acid (A=classical) A ESBL ESBL with activity against carbapenems carba ESBL ESBL, plasmid mediated, inhibited by clavulanic acid M (M=miscellaneous) ESCMID European Society of Clinical Microbiology and infectious diseases EU European Union EUCAST European committee on antimicrobial susceptibility testing GP General Practitioner ICD International classification of diseases ICU Intensive care unit IPSE Improved Patient Safety in Europe MIC Minimal inhibitory concentration MRB Multi resistant bacteria MRSA Methicillin resistant Staphylococus aureus NEPI the Network for Pharmaceutical Epidemiology NordicAST Nordic Committee on Antimicrobial Susceptibility Testing. OECD The Organisation for Economic Co-operation and Development OIE World organisation for animal health OTC Over the counter PcG Penicillin G (Benzylpenicillin) PcV Penicillin V PDD Prescribed daily dose PNSP/PRP Penicillin non-susceptible (resistant) pneumococci PPS Point prevalence study PRIS Primary care record of infections in Sweden PV-quality Quality register for primary care RAVE Search engine used for Primary care Register of Infections in Sweden ReAct Action on antibiotic resistance, independent global network ResNet Webb application for Resistance surveillance and quality control programme RIVM The National Institute for Public Health and the Environment, the Netherlands RTI Respiratory tract infections SAI Healthcare Antibiotics and Infection Tracking System SALAR the Swedish Association of Local Authorities and Regions SIR Swedish Intensive Care Registry SWEDISH WORK ON CONTAINMENT OF ANTIBIOTIC RESISTANCE 9 SIR Categorisation of infectious agents as Susceptible Intermediate or Resistant to particular antibiotics antibiotics SMI the Swedish Institute for Communicable Disease Control SmiNet Electronic notification of communicable diseases SRGA Swedish Reference Group for Antibiotics Strama Swedish strategic programme against antibiotic resistance SWEDRES/ A Report on Swedish Antibiotic Utilisation and Resistance in Human SVARM Medicine (SWEDRES) and Swedish Veterinary Antimicrobial Resistance Monitoring (SVARM) UK-NEQAS United Kingdom National External Quality UTI Urinary tract infections VAP Ventilator associated pneumonia VRE Vancomycin resistant enterococci WHO World Health Organisation 10 SWEDISH WORK ON CONTAINMENT OF ANTIBIOTIC RESISTANCE